Executive Summary

After its first phase of implementation from 2003 to 2008, the U.S. Congress reauthorized the President's Emergency Plan for AIDS Relief (PEPFAR) for a second five years. The following analysis offers a critique of the policy environment and country Partnership Frameworks for youth in PEPFAR's second phase, which began in 2009. At a time when young people ages 15-24 account for four in ten new HIV infections among adults,1 this in-depth review finds that PEPFAR has made some important progress towards advancing young people's sexual and reproductive health, but its policy environment for youth is characterized by omissions and inadequacy. The report concludes with a set of recommendations for the policymakers governing PEPFAR (the U.S. Congress, the Office of the U.S. Global AIDS Coordinator (OGAC) and Partner Country governments) to design and implement the bold policy needed to support youth sexual and reproductive health and rights.

HIV Remains a Serious Threat to Young People

Young people ages 15-24 represent 42 percent of all new HIV infections among adults aged 15 and older.1* Throughout the world, almost 2,500 youth ages 15 to 24 acquire HIV each day.2 Young women continue to be more vulnerable to the HIV epidemic than young men — young women comprise 64 percent of all young people with HIV, and in the hardest-hit region, Sub-Saharan Africa, young women comprise 71 percent of the cases among young people.2 While the vast majority (3.8 million/76 percent) of young people living with HIV or AIDS are in sub-Saharan Africa, many also reside in South and Southeast Asia (500,000/10 percent) and Latin America and the Caribbean (250,000/5 percent).2

Heterosexual sex is the primary mode of transmission for HIV in Sub-Saharan Africa and South and Southeast Asia.2 But around the world, commercial sex workers (CSWs), injection drug users (IDUs), and men who have sex with men (MSM) are at heightened risk.

In a study conducted in St. Petersburg, Russia, 33 percent of sex workers under 18 years of age were found to be HIV-positive.2

In a study conducted in Viet Nam, 48 percent of injecting drug users were less than 25 years old, 24 percent of them had started injecting within the previous 12 months, and of these, 28 percent were infected with HIV.2

In Cape Town, South Africa, HIV prevalence among MSM is estimated to be four times that of the general population, while in the Bahamas, 25 percent of MSM are HIV-positive.2

Research shows that a lack of information, skills, and access to services for youth fuel the epidemic. Globally, only 34 percent of young people (24 percent of young women and 36 percent of young men from low and middle income countries) can correctly answer the five basic questions about HIV and how to prevent it.3 Among countries with generalized† epidemics, fewer than 70 percent have implemented school-based HIV education in most or all districts, and only 61 percent have put in place HIV prevention programs for out-of-school youth. Where programs exist, their quality has often not been evaluated.4 Further, many young people do not have access to sexual health advice, condoms and other forms of contraception, or voluntary counseling and testing services for HIV and other STIs.2 Reproductive health services are seldom geared towards the needs of young people, who therefore tend to avoid them — putting themselves and their sexual partners at risk of HIV infection.5 Research around the world has found that comprehensive school and community-based HIV prevention programs and access to youth-friendly information and services help reduce HIV rates and improve risk behaviors among young people.6,7

PEPFAR, Past and Present

In 2003, President George W. Bush announced the creation of the President's Emergency Plan for AIDS Relief (PEPFAR), a popular bipartisan multibillion-dollar initiative to address the impact of HIV/AIDS on individuals, communities, and nations around the world. The first five years of PEPFAR focused on providing an emergency response to the pandemic by rapidly scaling up never-before-seen treatment efforts, transforming HIV and AIDS from a death sentence to a chronic illness for more than two million people.8 Originally authorized for U.S. $15 billion in funding over five years, Congress had appropriated more than U.S. $18 billion by the close of 2008 and over U.S. $31 billion by the close of 2011.9 The U.S. remains the single largest donor of HIV/AIDS prevention, treatment, and care, representing 51 percent of all HIV/AIDS funding around the world in 2007.10

While rapid scale-up was achieved, PEPFAR's first five years were implemented in a political climate that favored ideology over science in prevention policies and programs for youth.11 Its legislative skeleton and policy guidance mandated abstinence-until-marriage and be-faithful messaging for youth, ignoring the reality of sexual activity before or outside of marriage for millions of young people.12,13 Even further, its authorizing act permitted implementing organizations to refuse to dispense condoms on the basis of their moral beliefs,14 and no policy guidance was issued on prevention programming for three populations most at-risk for HIV: CSWs, MSM, and IDUs. Considering the scale of its impact in many low-resource countries, PEPFAR in its first five years imposed a policy regime that was at times unhelpful and even dangerous to helping vulnerable young people prevent transmission of HIV through sexual activity.

In 2008, Congress reauthorized PEPFAR for another five years through the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act (P.L.110-293, hereinafter known as Lantos-Hyde).15 In addition to a greater focus on women, Lantos-Hyde also permitted the use of PEPFAR funds for prevention, treatment, and care of Key Affected Populations (KAPs), especially commercial sex workers, injection drug users, and men who have sex with men. Another policy shift that occurred in the reauthorization of PEPFAR related to abstinence funding. Under the original law creating PEPFAR, countries were required to spend one-third of their funding for prevention activities on "abstinence-until-marriage and be faithful" programming.16 While Lantos-Hyde removed this harmful, ideological restriction, it replaced it with a "reporting requirement." This new provision requires countries with generalized epidemics to spend at least half of their sexual transmission prevention dollars on activities that support "abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction."15 If they fail to do so, OGAC must submit a justification to Congress for those countries.15

Finally, new authorizing legislation necessitated new interpretations of the law and as such, new policy guidance documents were issued. In addition, PEPFAR no longer signs legally binding "compacts" with bilateral recipients of aid, but rather signs non-binding "Partnership Frameworks" which are drafted largely based on the country government's existing health care plans.17

Understanding and Reviewing PEPFAR Youth Policy

PEPFAR's new structure prioritizes country ownership over one-size-fits-all approaches. This necessitates a nuanced approach to assessment which reflects progress and problems in both PEPFAR policy and in what partner governments choose to prioritize in their local responses to the epidemic. To do this, the author broke down PEPFAR documents into two sets. Set one includes documents drafted by the U.S. Congress and OGAC, which establish the PEPFAR "policy environment," including authorizing legislation (the Lantos-Hyde Act), the Five Year Strategy and its annexes, and Policy Guidance documents. Set two includes country Partnership Framework documents, which are written by country governments in consultation with PEPFAR in-country teams and reflect country priorities and programs. Both sets of documents were then analyzed according to nine indicators related to best practices in youth HIV and AIDS prevention and care policy.18

The nine youth-focused policy indicators include:

Promotion or requirement that comprehensive sex education (CSE) be provided for all youth

Emphasis on the meaningful inclusion of youth in the development, implementation and/or evaluation of youth HIV prevention and care strategies

Explicit calls for the integration of youth-friendly HIV/AIDS and family planning/reproductive health (FP/RH) services

Clear emphasis on specific prevention strategies for young people living with HIV or AIDS (YPLWHA)

Clear recommendations for the compilation and reporting of age-disaggregated data and statistics

Explicit inclusion of programs and strategies targeting young men who have sex with men, young commercial sex workers and young intravenous drug users

Language that identifies youth as a Key Affected Population

Policies and programs designed to reach at-risk and out-of-school youth

Results and Findings

Table 1 includes an analysis of each youth policy indicator, including a description of promising and problematic components of PEPFAR authorizing language, Five Year Strategy and annexes and Policy Guidance documents. Table 2 summarizes findings from a review of available country Partnership Frameworks.

Recommendations

While PEPFAR's progress towards a more favorable and empowering policy environment for youth is undeniable, so is the fact that significant policy impediments remain for youth in PEPFAR programs. This is evidenced not only by the problematic segmented approach to comprehensive prevention education in the second phase of PEPFAR, but also by the fact that over half of Partnership Frameworks failed to clearly prioritize youth sexual and reproductive health while none achieved an A grade. These recommendations offer PEPFAR's policymakers, from the U.S. Congress to OGAC to Partner Governments, the opportunity to prioritize and empower young people as part of the solution to the grand challenges posed by the global HIV/AIDS pandemic.

U.S. Congress

Amend Lantos-Hyde to:

a. Remove the Abstinence and Be Faithful Reporting Requirement. b. Include language on findings that explicitly indicates the effectiveness of comprehensive programs, including but not limited to, education about abstinence, fidelity, and correct and consistent use of condoms, and notes their enhanced effectiveness when introduced to youth before becoming sexually active. c. Include language on findings regarding youth within populations of MSM, CSW, and IDUs. d. Explicitly permit the use of PEPFAR funds for family planning services and for the purchase of family planning commodities besides condoms in order to truly integrate HIV-FP/RH services. e. Change the definition of OVC to better reflect the fact that the majority of orphans and vulnerable children are, in fact, adolescents and, therefore, require more specialized programming.

Issue a clear and unequivocal statement to U.S. missions, implementing partners, and country teams that the Guidance on the Prevention of Sexually Transmitted HIV Infections supersedes the ABC guidance, and remove the previous guidance from the PEPFAR website, or at the very least, include a disclaimer on the old guidance that it is no longer in effect.

Update the youth section of the Guidance on the Prevention of Sexually Transmitted HIV Infections to include data on the ineffectiveness of teaching youth only about abstinence, and accurately portray evidence that demonstrates the effect of comprehensive sex education as a sustainable prevention intervention.

a. Defines comprehensive prevention education for youth in a manner that is consistent with standards of age-appropriate, comprehensive sex education curricula and which introduces education about contraception and condoms, in addition to information on delay of sexual debut, before becoming sexually active, and partner reduction.7, 34 b. Reinforces the need for the participation of youth civil society at all levels of implementation and outlines ways that countries can achieve this, using best practice examples from partner countries. c. Reviews best practice models for youth-friendly service centers throughout PEPFAR programs that integrate HIV with FP/RH services in quality care for young people. d. Transforms systemic data collection to disaggregate the majority of data on the basis of five age groups: 0-9, 10-14, 15-19, 20-24, and 25-49 to fill in existing gaps on knowledge about youth populations. e. Outlines a comprehensive policy reform agenda to reduce HIV infection and improve treatment and care among young people by focusing on access and empowerment. Reforms might include changing health care and family planning commodity access laws for minors or adoption of compulsory secondary education financed by the state, among other reforms, depending on country context. f. Offers policy guidance on prevention, treatment, and care of youth who are part of other Key Affected Populations such as MSM, CSW, and IDUs. g. Explicitly recognizes youth in general as a Key Affected Population and tailors programming to meet their unique needs.

Country Governments and PEPFAR Implementation Teams

Create institutional mechanisms for youth CSOs to participate in PEPFAR implementation at all levels. Examples of such mechanisms can be the appointment of youth representatives on overarching policy/advisory boards, the creation of youth-specific advisory boards comprised of a majority of youth representatives, the inclusion of youth participants in country and regional workshops, the development of electronic discussion boards to engage youth within PEPFAR countries, the use of e-consultations to receive input from youth across PEPFAR countries, the hiring of youth liaisons at each country office, and reporting requirements on the inclusion and integration of youth in programming and decision-making.

Based on Table 2, amend Partnership Frameworks to improve country focus on youth sexual and reproductive health and rights.

Prioritize grants for HIV prevention for youth to organizations with expertise in youth and both FP/RH and HIV prevention.

Key Limitations and Assumptions of This Analysis

The analysis presented here calls attention to the conflicting nature of youth policy in PEPFAR's second phase. The hope is that it can raise awareness of progress while also distilling the root causes of limitations to young people's access to comprehensive information, skills training, and health services in PEPFAR policy. The report's analytical approach is not without its limitations and key assumptions, however, and all readers should take them into consideration when interpreting the findings.

First, the range of documents analyzed did not include Country Operational Plans (COPs) and OGAC Reports to Congress. COP documents are submitted annually to OGAC and offer detailed descriptions of the organizations and agencies receiving PEPFAR funds and the programs they plan to implement. These documents can be valuable for understanding the on-the-ground implementation of PEFPAR policy. Yet for the purposes of this analysis, the wide variability in the detail of different COPs and the lack of availability of some countries and years made them an inconsistent resource on which to base the findings. Further, OGAC Reports to Congress were not available for public review at the time of this publication. These reports would have given valuable insight into the way OGAC explains the allocation of funding for the prevention of sexual transmission specific to the reporting requirement mandated in the legislation.

Second, the analysis and findings rest on the key assump- tion that confusion in PEPFAR policy translates to confu- sion in PEPFAR program implementation. For example, while it is promising that the Five Year Strategy sets a target of comprehensive knowledge of HIV prevention among 100 percent of youth, the reauthorizing legislation still requires reports on the expenditure of abstinence and be faithful program spending. This creates an inherently conflicting policy environment. The assump- tion is that on the ground, this has the potential to limit youth access to comprehensive information. However, given limited resources, our analysis did not include in- terviews or questionnaires of program implementers to see if this policy contradiction in fact limits their ability to provide comprehensive programming for youth. We hope that the policy analysis presented here can shed light for implementers and policymakers alike on possible sources of confusion in program implementation.

Conclusions: Progress Stunted

There are undoubtedly promising components visible for youth sexual and reproductive health and rights in the second phase of PEPFAR, from the Five Year Strategy's bold target of achieving comprehensive knowledge of HIV transmission and prevention among 100 percent of youth in countries with generalized epidemics, to the need for youth civil society participation and inclusion of young people in policy and programmatic considerations for Key Affected Populations. However, progress in these areas is marred by inadequate or confusing policies in others. Meanwhile, the many failing grades in the aggregate analysis of Partnership Frameworks are cause for concern. But despite their limitations, the analysis of these documents at least offers a snapshot of the broad level prioritization of youth in PEPFAR countries and suggests evidence that there is both some hope for progress, and much work remaining, in order to ensure that adolescents and young people in PEPFAR countries are empowered in shaping their own futures and the futures of their countries.

* The United Nations defines adolescents as individuals aged 10-19, youth as those aged 15-24, and young people as the full range from 10-24. This brief will use the terms youth and young people interchangeably and will identify adolescents separately when warranted.

† Generalized epidemics are considered those where transmission occurs largely in the general population, compared with concentrated epidemics where transmission occurs within Key Affected Populations, including commercial sex workers, injection drug users, and men who have sex with men.

10. Kates, Jennifer, Lief, E. and Avila, C. "Financing the response to AIDS in low- and middle-income countries: International assistance from the G8, European Commission, and other donor Governments in 2008." Kaiser Family Foundation and UNAIDS, Geneva, Menlo Park: July, 2009. http://www.kff.org/hivaids/upload/7347-052.pdf. Accessed on 1 October 2011.

12. For history of the ABC policy see Hardee, Karen and Gribble J., Weber, S., Manchester, T., and Wood, M. "Reclaiming the ABCs—The Creation and Evolution of the ABC Approach." Population Action International, Washington: August, 2008. http://209.68.15.158/Publications/Reports/Reclaiming_the_ABCs. Accessed on 1 October 2011.

17. For a clear breakdown of PEPFAR's governing structure and implementation process, see "President's Emergency Plan for AIDS Relief: How PEPFAR Works." Avert, West Sussex, 2011. http://www.avert.org/pepfar.htm. Accessed on 1 October 2011.

18. These policy areas were derived based on a review of existing literature on public health policy for youth sexual and reproductive health and rights in the response to the global HIV and AIDS pandemic. See: Dhingra, N. (2007); Hardee, K., et al (2008); UNICEF (2011); UNAIDS (2011); UNICEF (2010); Boonstra, H. (2011); Kirby, Douglas, Laris, BA, Rolleri, L. "Sex and HIV Education Programs: Their Impact on Sexual Behaviors of Young People Throughout the World," Journal of Adolescent Health, Vol. 40: 2007, pp. 206-217. http://www.ncbi.nlm.nih.gov/pubmed/17321420?dopt=AbstractPlus. Accessed on 1 October 2011; "Young People Most at Risk of HIV: A Meeting Report and Discussion Paper from the Interagency Youth Working Group, U.S. Agency for International Development, the Joint United Nations Programme on HIV/AIDS (UNAIDS) Inter- Agency Task Team on HIV and Young People, and FHI." Family Health International, Research Triangle Park, NC: 2010. http://www.iywg.org/sites/default/files/Young_Most_Risk.pdf. Accessed on 1 October 2011.

* Denotes Regional Partnership Frameworks. In the Caribbean, government partners include: Antigua and Barbuda, The Bahamas, Barbados, Belize, Dominica, Grenada, Jamaica, St. Kitts and Nevis, St. Lucia, St. Vincent and the Grenadines, Suriname, and Trinidad and Tobago. In Central America, government partners include Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama. Belize appears to be a partner in both regional frameworks.

33. The presentation of data from Malawi is skewed. The Malawi Partnership Framework specifically states that "well performing youth programs" funded by the Global Fund to Fight AIDS, TB, and Malaria (GFATM) will continue to be implemented. The Partnership Framework focuses mainly on PEPFAR-sponsored interventions, which because of support for youth programs from GFATM, focus on adult campaigns.